The present invention is generally directed to a system for investigating and reducing the occurrence of undesirable incidents, such as industrial accidents. More specifically, the invention is directed to a system for identifying a human action, or lack of action, that represents an underlying cause of an incident, and suggesting corrective action to reduce the probability of a future occurrence of a similar incident. This specification includes a source code microfiche appendix comprising eight slides with a total of 684 frames.
Considerable monetary and other losses occur due to various unanticipated and unwanted incidents caused by things such as employee action or inaction. For example, industrial incidents cause millions of dollars in lost profits annually. Transportation incidents, including rail, air, and shipping incidents, result not only in lost revenue, but also loss of life and environmental damage. Fortunately, most of these incidents can be prevented if business managers understand and eliminate the underlying causes of such incidents.
Consistently, it has been determined that human action, or lack of action, is the underlying cause of a great number of these incidents. Even when an equipment malfunction is a contributing factor in causing an incident, often the equipment malfunctioned due to human oversight. Such human oversight includes design flaws, manufacturing errors, lack of proper maintenance, or incorrect operation of the equipment.
Identifying underlying causes provides for the development of effective corrective actions for the real problems that cause, or significantly contribute to, incidents. Implementation of effective corrective action is the preferred means to achieve dramatic, lasting reductions in the numbers of repeat incidents. Thus, to prevent the occurrence of a costly incident, the underlying cause of the incident should first be identified, and then a specific corrective action is implemented directed to eliminating the specific underlying cause.
Therefore, a system is needed that guides a business manager to an underlying cause of an incident, and that suggests corrective actions that may be implemented to eliminate the underlying cause.
The foregoing and other needs are met by a computer-implemented system for determining, by logical progression through multiple analysis levels, a human factor that represents a root cause of a particular incident. The system begins at a broad analysis level and progresses through more narrow analysis levels to a root cause level. Each analysis level includes multiple causal factor categories, with each causal factor category branching into causal factor subcategories that reside on a more narrow analysis level.
The system includes an information input device for inputting incident information relating to the particular incident and for converting the incident information into a system-compatible format. The system also includes a memory device for storing a causal information database that provides a relationship between the multiple analysis levels and causal factor categories and between causal factor categories and root causes. The causal information database stored in the memory device also relates root causes to corrective actions that may be implemented to prevent future occurrences of the incidents. A processor, which is connected to the information input device and to the memory device, accesses the causal information database and determines a human factor that represents a root cause of the particular incident. This determination is made by logical progression through the multiple analysis levels based upon the incident information from the information input device. The processor logically progresses through the multiple analysis levels by selecting, based upon the incident information, an appropriate causal factor category at each analysis level. The processor accesses the causal information database and determines at least one corrective action that may be implemented to prevent future occurrences of the particular incident based on the root cause of the particular incident. The system further includes a display device connected to the processor for displaying a graphic representation of the multiple analysis levels. The graphic representation indicates the causal factor categories selected by the processor in determining the root cause of the particular incident. The display device also displays the corrective actions that may be implemented to prevent future occurrences of the particular incident.
Thus, the present invention provides a user with a powerful tool for identifying root causes of incidents and determining correction actions to prevent a recurrence of the incidents. The invention provides links between causes and suggested corrective actions at the root cause level, not at higher levels in the causal database structure. Corrective actions designed to eliminate root causes are more likely to prevent recurrences of an incident than do corrective actions that are based upon less specific information. By providing links between root causes and corrective actions, the invention provides suggestions for the most effective corrective actions.